Nursing Care Plan

Topics: Dehydration, Nutrition, Nursing care plan Pages: 4 (1414 words) Published: April 9, 2013
Assessment| Nursing Diagnosis| Goals & Expected outcomes| Nursing Interventions| Rationales| Methods of Evaluation| Name of client: Mrs. Tam Age: 65 Sex: Female Student ID:1155016494 Assessment date: 29/11/12 Medical Diagnosis: 1. Lower limbs edema 2. Low albumin level 3. hypokalemia and hypocalcaemia 4. Anemia Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to vomiting after eating as evidenced by food intake less than the recommended daily allowance and decreased albumin level.

Name of client: Mrs. Tam Age: 65 Sex: Female Student ID:1155016494 Assessment date: 29/11/12 Medical Diagnosis: 1. Lower limbs edema 2. Low albumin level 3. hypokalemia and hypocalcaemia 4. Anemia Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to vomiting after eating as evidenced by food intake less than the recommended daily allowance and decreased albumin level.

Subjective data :Mrs. Tam said she would vomit after eating .Objective data : 1. Mrs. Tam was diagnosed to have malnutrition. 2. Mrs. Tam daily input was only 700ml and 650ml on 27/11/12 and 28/11/12 respectively.Dysfunctional Health Pattern:Nutrition-metabolic Pattern | Problem:Imbalanced nutrition: less than body requirements Etiology:Vomiting after eatingSigns & symptoms:food intake less than the recommended daily allowance and decreased albumin level.| Goals: Mrs. Tam will ingest daily nutritional requirements in accordance with activity level and metabolic needs.Expected outcomes: 1. Mrs. Tam can verbalize the importance of good nutrition on 1/12/12. 2. Mrs. Tam can states a selection of food or meals that can provide balanced and sufficient nutrients for her on 1/12/12. 3. Mrs. Tam will report absence of vomiting after eating since 1/12/12. 4. Mrs. Tam’s blood albumin level will continuously stay in normal range 5. Mrs. Tam will intake more food daily.| 1. Explain the need for adequate...
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